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Friday SE, Oyama MA, Massey LK, Aronson LR. Effect of metastatic calcification on complication rate and survival in 74 renal transplant cats (1998-2020). Vet Surg 2023; 52:952-960. [PMID: 37395131 DOI: 10.1111/vsu.13984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/25/2023] [Accepted: 05/29/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE To report the incidence of metastatic calcification in cats with renal failure presenting for renal transplantation, and to determine if metastatic calcification detected prior to renal transplantation is associated with complication rates and patient survival. STUDY DESIGN Retrospective case series. SAMPLE POPULATION Seventy-four cats. METHODS In imaging studies, 178 feline renal transplant recipients from 1998 to 2020 were evaluated for metastatic calcification. Demographic, clinicopathological data, intraoperative complications, postoperative complications, need for hemodialysis, and survival times were recorded. Exclusion criteria were cats lacking imaging reports and cats with gastric, renal, or tracheal/bronchial calcification alone. Univariable and multivariable analyses were performed to determine variables that were independently associated with survival. Kaplan-Meier analysis was used to generate survival plots and estimate median survival times with a 95% confidence interval (CI). RESULTS Seventy four of 178 cats met the inclusion criteria. Fifteen of 74 (20.3%) cats had metastatic calcification prior to renal transplantation. Twelve of 74 (16.2%) cats developed calcification following transplantation, and 47 of 74 (63.5%) cats had no calcification during the study period. Median follow-up time was 472 days, with a range of 0-1825 days. Cats with pretransplant calcification had shorter median survival times (147 days) than cats without calcification (646 days) (p = .0013). Metastatic calcification pretransplant was associated with an increased risk of death by 240% (95% CI, 1.22-4.71). CONCLUSION Metastatic calcification in renal transplant cats is a negative prognostic indicator and is associated with decreased survival times. CLINICAL SIGNIFICANCE These findings may help guide therapeutic recommendations and owner expectations in cats undergoing renal transplantation.
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Affiliation(s)
- Sarah E Friday
- Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark A Oyama
- Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura K Massey
- Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lillian R Aronson
- Matthew J. Ryan Veterinary Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Zhao H, Liu H, Liu Y, Jin J, He Q, Lin B. The role of extracellular vesicles in vascular calcification in chronic kidney disease. Front Med (Lausanne) 2022; 9:997554. [DOI: 10.3389/fmed.2022.997554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
Widespread vascular calcification (VC) in patients with chronic kidney disease (CKD) is the pathological basis for the development of cardiovascular disease, and VC has been identified as an independent risk factor for increased cardiovascular mortality in cases of CKD. While VC was earlier thought to be a passive deposition process following calcium and phosphorus supersaturation, recent studies have suggested that it is an active, modifiable, biological process similar to bone development. The involvement of extracellular vesicles (EVs) in the process of VC has been reported as an important transporter of material transport and intercellular communication. This paper reviews the mechanism of the role of EVs, especially exosomes, in VC and the regulation of VC by stem cell-derived EVs, and discusses the possible and promising application of related therapeutic targets in the clinical setting.
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3
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Do Van T, Nguyen Minh T, Dao Bui Quy Q, Pham Quoc T, Nguyen Duy T, Nguyen Trung K, Nguyen Cong H, Le Thi Huong L, Bui Thi Thu H, Tran Viet T, Do Q, Can Van M, Le Viet T. Serum osteoprotegerin level in hemodialysis patients using low-flux reused dialyzer in relation to atherosclerosis. J Clin Lab Anal 2021; 35:e23886. [PMID: 34173983 PMCID: PMC8373337 DOI: 10.1002/jcla.23886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS To assess the relation of high serum OPG level and carotid atherosclerosis in maintenance hemodialysis (MHD) patients using low-flux reused dialyzer. MATERIALS AND METHODS We examined 209 MHD patients with and without carotid atherosclerosis (83 patients and 126 patients) to establish the relation between OPG and atherosclerosis. RESULTS The proportion of carotid atherosclerosis was 39.7%. The median serum OPG level was 45.3 pmol/L. Serum OPG had a good predicting value for atherosclerosis in MHD patients using low-flux reused dialyzer (AUC = 0.934, p < 0.001, cutoff value = 43.35 pmol/L, Se = 81.3%, Sp = 90.9%). CONCLUSIONS In this study, serum OPG had a good predicting value for atherosclerosis in MHD patients using low-flux reused dialyzer.
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Affiliation(s)
- Tung Do Van
- Thai Nguyen National Hospital, Thai Nguyen, Viet Nam.,Viet Nam Military Medical University, Ha Noi, Viet Nam
| | | | | | - Toan Pham Quoc
- Viet Nam Military Medical University, Ha Noi, Viet Nam.,Military Hospital 103, Ha Noi, Viet Nam
| | - Toan Nguyen Duy
- Viet Nam Military Medical University, Ha Noi, Viet Nam.,Military Hospital 103, Ha Noi, Viet Nam
| | - Kien Nguyen Trung
- Viet Nam Military Medical University, Ha Noi, Viet Nam.,Military Hospital 103, Ha Noi, Viet Nam
| | | | | | | | - Tien Tran Viet
- Viet Nam Military Medical University, Ha Noi, Viet Nam.,Military Hospital 103, Ha Noi, Viet Nam
| | - Quyet Do
- Viet Nam Military Medical University, Ha Noi, Viet Nam
| | - Mao Can Van
- Viet Nam Military Medical University, Ha Noi, Viet Nam
| | - Thang Le Viet
- Viet Nam Military Medical University, Ha Noi, Viet Nam.,Military Hospital 103, Ha Noi, Viet Nam
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4
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Huang QX, Li JB, Huang N, Huang XW, Li YL, Huang FX. Elevated Osteoprotegerin Concentration Predicts Increased Risk of Cardiovascular Mortality in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Kidney Blood Press Res 2020; 45:565-575. [PMID: 32721972 DOI: 10.1159/000508978] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 05/26/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Studies have shown inconsistent results regarding the association between osteoprotegerin (OPG) concentration and cardiovascular mortality in patients with chronic kidney disease (CKD). This systematic review and meta-analysis aims to investigate the association between OPG concentration and cardiovascular mortality in patients with CKD. METHODS Between January 1970 and February 2020, the PubMed, EMBASE, and Cochrane Library databases were searched for eligible studies investigating the association between OPG concentration and cardiovascular mortality in patients with CKD. Pooled hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were calculated using random effects models. RESULTS In total, 10 studies comprising 2,120 patients (including 1,723 receiving dialysis) with CKD were included. The included studies were considered to be of fair to high quality. Patients in the highest OPG concentration group had a significantly higher risk of cardiovascular mortality (4 studies; adjusted HR, 2.05; 95% CI, 1.39-3.00) than patients in the low OPG concentration group. An increase of 1 pmol/L in OPG concentration was associated with a 4% increased risk of cardiovascular mortality (6 studies; adjusted HR, 1.04; 95% CI, 1.02-1.07). CONCLUSION Elevated OPG concentrations are associated with an increased risk of cardiovascular death in patients with CKD.
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Affiliation(s)
- Qing-Xiu Huang
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, China
| | - Jian-Bo Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Xiao-Wen Huang
- Department of Ultrasonography, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, China
| | - Yan-Lin Li
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, China
| | - Feng-Xian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, .,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China,
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5
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Chen NX, O'Neill KD, Moe SM. Matrix vesicles induce calcification of recipient vascular smooth muscle cells through multiple signaling pathways. Kidney Int 2018; 93:343-354. [PMID: 29032812 PMCID: PMC8211355 DOI: 10.1016/j.kint.2017.07.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 12/19/2022]
Abstract
In patients with chronic kidney and end-stage renal diseases, the major risk factor for progression of arterial calcification is the presence of existing (baseline) calcification. Here, we tested whether calcification of arteries is extended from calcified vascular smooth muscle cells (VSMCs) to adjacent normal cells by matrix vesicle-induced alteration of cell signaling. Matrix vesicles isolated from VSMC of rats with chronic kidney disease were co-cultured with VSMCs from normal littermates. Endocytosis of vesicles by recipient cells was confirmed by confocal microscopy. The addition of cellular matrix vesicles with characteristics of exosomes and low fetuin-A content enhanced the calcification of recipient VSMC. Further, only cellular-derived matrix vesicles induced an increase in intracellular calcium ion concentration, NOX1 (NADPH oxidase) and the anti-oxidant superoxide dismutase-2 in recipient normal VSMC. The increase in intracellular calcium ion concentration was due to release from endoplasmic reticulum and partially attributed to the activation of both NOX1 and mitogen-activated protein kinase (MEK1 and Erk1/2) signaling, since inhibiting both pathways blocked the increase in intracellular calcium ion in recipient VSMC. In contrast, matrix vesicles isolated from the media had no effect on the intracellular calcium ion concentration or MEK1 signaling, and did not induce calcification. However, media matrix vesicles did increase Erk1/2, although not to the level of cellular matrix vesicles, and NOX1 expression. Blockade of NOX activity further inhibited the cellular matrix vesicle-induced accelerated calcification of recipient VSMC, suggesting a potential therapeutic role of such inhibition. Thus, addition of cellular-derived matrix vesicles from calcifying VSMC can accelerate calcification by inducing cell signaling changes and phenotypic alteration of recipient VSMC.
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MESH Headings
- Animals
- Calcium/metabolism
- Cells, Cultured
- Coculture Techniques
- Disease Models, Animal
- Endocytosis
- Exosomes/metabolism
- Exosomes/ultrastructure
- Extracellular Matrix/metabolism
- Extracellular Matrix/ultrastructure
- Extracellular Signal-Regulated MAP Kinases/metabolism
- MAP Kinase Kinase 1/metabolism
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/ultrastructure
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/ultrastructure
- NADPH Oxidase 1/metabolism
- Phenotype
- Rats
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/pathology
- Signal Transduction
- Superoxide Dismutase/metabolism
- Vascular Calcification/metabolism
- Vascular Calcification/pathology
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Affiliation(s)
- Neal X Chen
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kalisha D O'Neill
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Roduebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA.
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6
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Molnar AO, Biyani M, Hammond I, Harmon JP, Lavoie S, McCormick B, Sood MM, Wagner J, Pena E, Zimmerman DL. Lower serum magnesium is associated with vascular calcification in peritoneal dialysis patients: a cross sectional study. BMC Nephrol 2017; 18:129. [PMID: 28385153 PMCID: PMC5382660 DOI: 10.1186/s12882-017-0549-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/03/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Coronary artery calcification (CAC) is highly prevalent among dialysis patients and is associated with increased cardiovascular and all cause mortality. Magnesium (Mg) inhibits vascular calcification in animal and in-vitro studies but whether the same effect occurs in humans is uncertain. METHODS A single centre cross-sectional study of 80 prevalent peritoneal dialysis (PD) patients; on PD only for a minimum of 3 months. A radiologist blinded to patient status calculated their abdominal aortic calcification (AAC) scores on lateral lumbar spine radiographs, a validated surrogate for CAC. RESULTS Eighty patients provided informed consent and underwent lumbar spine radiography. The mean serum Mg was 0.8 mmol/L (standard deviation 0.2) and mean AAC score 8.9 (minimum 0, maximum 24). A higher serum Mg level was associated with a lower AAC score (R 2 = 0.06, unstandardized coefficient [B] = -7.81, p = 0.03), and remained after adjustment for age, serum phosphate, serum parathyroid hormone, low-density lipoprotein cholesterol, smoking history, and diabetes (model adjusted R 2 = 0.36, serum Mg and AAC score B = -11.44, p = 0.00). This translates to a 0.1 mmol/L increase in serum Mg being independently associated with a 1.1-point decrease in AAC score. CONCLUSIONS Our findings suggest that Mg may inhibit vascular calcification. If this association is replicated across larger studies with serial Mg and vascular calcification measurements, interventions that increase serum Mg and their effect on vascular calcification warrant further investigation in the PD population.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mohan Biyani
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ian Hammond
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada.,Department of Medical Imaging, The Ottawa Hospital Ottawa, Ottawa, ON, Canada
| | - John Paul Harmon
- Division of Nephrology, Department of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Susan Lavoie
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Brendan McCormick
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jessica Wagner
- Division of Nephrology, Department of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Elena Pena
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada.,Department of Medical Imaging, The Ottawa Hospital Ottawa, Ottawa, ON, Canada
| | - Deborah L Zimmerman
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,The Ottawa Hospital, Riverside Campus 1967 Riverside Drive, Ottawa, ON, Canada, K1H 7W9.
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7
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Ye M, Tian N, Liu Y, Li W, Lin H, Fan R, Li C, Liu D, Yao F. High Serum Phosphorus Level Is Associated with Left Ventricular Diastolic Dysfunction in Peritoneal Dialysis Patients. PLoS One 2016; 11:e0163659. [PMID: 27661984 PMCID: PMC5035053 DOI: 10.1371/journal.pone.0163659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 09/12/2016] [Indexed: 12/28/2022] Open
Abstract
Objectives We initiated this study to explore the relationships of serum phosphorus level with left ventricular ultrasound features and diastolic function in peritoneal dialysis (PD) patients. Methods 174 patients with end-stage renal disease (ESRD) receiving PD were enrolled in this retrospective observational study. Conventional echocardiography examination and tissue Doppler imaging (TDI) were performed in each patient. Clinical information and laboratory data were also collected. Analyses of echocardiographic features were performed according to phosphorus quartiles groups. And multivariate regression models were used to determine the association between serum phosphorus and Left ventricular diastolic dysfunction (LVDD). Results With the increase of serum phosphorus levels, patients on PD showed an increased tissue Doppler-derived E/e’ ratio of lateral wall (P < 0.001), indicating a deterioration of left ventricular diastolic function. Steady growths of left atrium and left ventricular diameters as well as increase of left ventricular muscle mass were also observed across the increasing quartiles of phosphorus, while left ventricular ejection fraction remained normal. In a multivariate analysis, the regression coefficient for E/e’ ratio in the highest phosphorus quartile was almost threefold higher relative to those in the lowest quartile group. And compared with patients in the lowest phosphorus quartile (<1.34 mmol/L) those in the highest phosphorus quartile (>1.95 mmol/L) had a more than fivefold increased odds of E/e’ ratio >15. Conclusions Our study showed an early impairment of left ventricular diastolic function in peritoneal dialysis patients. High serum phosphorus level was independently associated with greater risk of LVDD in these patients. Whether serum phosphorus will be a useful target for prevention or improvement of LVDD remains to be proved by further studies.
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Affiliation(s)
- Min Ye
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Na Tian
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, PR China
| | - Yanqiu Liu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Wei Li
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Hong Lin
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Rui Fan
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Cuiling Li
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Donghong Liu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
- * E-mail: (FJY); (DHL)
| | - Fengjuan Yao
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
- * E-mail: (FJY); (DHL)
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8
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Brandenburg VM, Floege J. Adynamic bone disease-bone and beyond. NDT Plus 2015; 1:135-47. [PMID: 25983860 PMCID: PMC4421169 DOI: 10.1093/ndtplus/sfn040] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2008] [Accepted: 03/18/2008] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vincent M Brandenburg
- Department of Nephrology and Clinical Immunology , RWTH University Hospital Aachen , Pauwelsstrasse 30, Aachen, D-52057 , Germany
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology , RWTH University Hospital Aachen , Pauwelsstrasse 30, Aachen, D-52057 , Germany
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9
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Fissell RB, Karaboyas A, Bieber BA, Sen A, Li Y, Lopes AA, Akiba T, Bommer J, Ethier J, Jadoul M, Pisoni RL, Robinson BM, Tentori F. Phosphate binder pill burden, patient-reported non-adherence, and mineral bone disorder markers: Findings from the DOPPS. Hemodial Int 2015; 20:38-49. [PMID: 25975222 DOI: 10.1111/hdi.12315] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Because of multiple comorbidities, hemodialysis (HD) patients are prescribed many oral medications, including phosphate binders (PBs), often resulting in a high "pill burden." Using data from the international Dialysis Outcomes and Practice Patterns Study (DOPPS), we assessed associations between PB pill burden, patient-reported PB non-adherence, and levels of serum phosphorus (SPhos) and parathyroid hormone (PTH) using standard regression analyses. The study included data collected from 5262 HD patients from dialysis units participating in the DOPPS in 12 countries. PB prescription ranged from a mean of 7.4 pills per day in the United States to 3.9 pills per day in France. About half of the patients were prescribed at least 6 PB pills per day, and 13% were prescribed at least 12 PB pills per day. Overall, the proportion of patients who reported skipping PBs at least once in the past month was 45% overall, ranging from 33% in Belgium to 57% in the United States. There was a trend toward greater PB non-adherence and a higher number of prescribed PB pills per day. Non-adherence to PB prescription was associated with high SPhos (>5.5 mg/dL) and PTH (>600 pg/mL). Adherence to PB is a challenge for many HD patients and may be related to the number of PB pills prescribed. Prescription of a simplified PB regimen could improve patient adherence and perhaps improve SPhos and PTH levels.
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Affiliation(s)
| | - Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ananda Sen
- University of Michigan, Ann Arbor, Michigan, USA
| | - Yun Li
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA.,University of Michigan, Ann Arbor, Michigan, USA
| | - Antonio A Lopes
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | | | | | - Jean Ethier
- Center Hospital de University of Montreal, Montreal, Quebec, Canada
| | - Michel Jadoul
- Cliniques St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA.,University of Michigan, Ann Arbor, Michigan, USA
| | - Francesca Tentori
- Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
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10
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Rivara MB, Ravel V, Kalantar-Zadeh K, Streja E, Lau WL, Nissenson AR, Kestenbaum B, de Boer IH, Himmelfarb J, Mehrotra R. Uncorrected and Albumin-Corrected Calcium, Phosphorus, and Mortality in Patients Undergoing Maintenance Dialysis. J Am Soc Nephrol 2015; 26:1671-81. [PMID: 25613037 DOI: 10.1681/asn.2014050472] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
Uncorrected serum calcium concentration is the first mineral metabolism metric planned for use as a quality measure in the United States ESRD population. Few studies in patients undergoing either peritoneal dialysis (PD) or hemodialysis (HD) have assessed the association of uncorrected serum calcium concentration with clinical outcomes. We obtained data from 129,076 patients on dialysis (PD, 10,066; HD, 119,010) treated in DaVita, Inc. facilities between July 1, 2001, and June 30, 2006. After adjustment for potential confounders, uncorrected serum calcium <8.5 and ≥10.2 mg/dl were associated with excess mortality in patients on PD or HD (comparison group uncorrected calcium 9.0 to <9.5 mg/dl). Additional adjustment for serum albumin concentration substantially attenuated the all-cause mortality hazard ratios (HRs) associated with uncorrected calcium <8.5 mg/dl (HR, 1.29; 95% confidence interval [95% CI], 1.16 to 1.44 for PD; HR, 1.17; 95% CI, 1.13 to 1.20 for HD) and amplified the HRs associated with calcium ≥10.2 mg/dl (HR, 1.65; 95% CI, 1.42 to 1.91 for PD; HR, 1.59; 95% CI, 1.53 to 1.65 for HD). Albumin-corrected calcium ≥10.2 mg/dl and serum phosphorus ≥6.4 mg/dl were also associated with increased risk for death, irrespective of dialysis modality. In summary, in a large nationally representative cohort of patients on dialysis, abnormalities in markers of mineral metabolism, particularly high concentrations of serum calcium and phosphorus, were associated with increased mortality risk. Additional studies are needed to investigate whether control of hypercalcemia and hyperphosphatemia in patients undergoing dialysis results in improved clinical outcomes.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Vanessa Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California; Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Allen R Nissenson
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; and DaVita, Inc., El Segundo, California
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, Washington
| | | | - Rajnish Mehrotra
- Kidney Research Institute, University of Washington, Seattle, Washington
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11
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Shah A, Miller CJ, Nast CC, Adams MD, Truitt B, Tayek JA, Tong L, Mehtani P, Monteon F, Sedor JR, Clinkenbeard EL, White K, Mehrotra R, LaPage J, Dickson P, Adler SG, Iyengar SK. Severe vascular calcification and tumoral calcinosis in a family with hyperphosphatemia: a fibroblast growth factor 23 mutation identified by exome sequencing. Nephrol Dial Transplant 2014; 29:2235-43. [PMID: 25378588 DOI: 10.1093/ndt/gfu324] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Tumoral calcinosis is an autosomal recessive disorder characterized by ectopic calcification and hyperphosphatemia. METHODS We describe a family with tumoral calcinosis requiring amputations. The predominant metabolic anomaly identified in three affected family members was hyperphosphatemia. Biochemical and phenotypic analysis of 13 kindred members, together with exome analysis of 6 members, was performed. RESULTS We identified a novel Q67K mutation in fibroblast growth factor 23 (FGF23), segregating with a null (deletion) allele on the other FGF23 homologue in three affected members. Affected siblings had high circulating plasma C-terminal FGF23 levels, but undetectable intact FGF23 or N-terminal FGF23, leading to loss of FGF23 function. CONCLUSIONS This suggests that in human, as in experimental models, severe prolonged hyperphosphatemia may be sufficient to produce bone differentiation proteins in vascular cells, and vascular calcification severe enough to require amputation. Genetic modifiers may contribute to the phenotypic variation within and between families.
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Affiliation(s)
- Anuja Shah
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Clinton J Miller
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Cynthia C Nast
- Division of Pathology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Mark D Adams
- J. Craig Venter Institute, San Diego, CA 92121, USA
| | - Barbara Truitt
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - John A Tayek
- Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Lili Tong
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Parag Mehtani
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Francisco Monteon
- Unidad de Nefrologia y Transplante, Hospital Mexico-Americano, Guadalajara, Jalisco, Mexico
| | - John R Sedor
- Department of Medicine, MetroHealth Medical Center, Cleveland, OH 44109, USA
| | - Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kenneth White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Rajnish Mehrotra
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Janine LaPage
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Patricia Dickson
- Division of Medical Genetics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Sharon G Adler
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Sudha K Iyengar
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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No independent association of serum phosphorus with risk for death or progression to end-stage renal disease in a large screen for chronic kidney disease. Kidney Int 2013; 84:989-97. [PMID: 23615501 DOI: 10.1038/ki.2013.145] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/01/2013] [Accepted: 02/14/2013] [Indexed: 02/06/2023]
Abstract
Whether higher serum phosphorus levels are associated with a higher risk for death and/or progression of chronic kidney disease (CKD) is not well established, and whether the association is confounded by access and barriers to care is unknown. To answer these questions, data of 10,672 individuals identified to have CKD (estimated glomerular filtration rate <60 ml/min per 1.73 m(2)) from those participating in a community-based screening program were analyzed. Over a median follow-up of 2.3 years, there was no association between quartiles of serum phosphorus and all-cause mortality (adjusted hazards ratio for serum phosphorus over 3.3 to 3.7, over 3.7 to 4.1, and over 4.1 mg/dl, respectively: 1.22 (0.95-1.56), 1.00 (0.76-1.32), and 1.00 (0.75-1.33); reference, serum phosphorus of 3.3 mg/dl and below). Individuals in the highest quartile for serum phosphorus had a significantly higher risk for progression to end-stage renal disease (ESRD) (unadjusted hazards ratio, 6.72 (4.16-10.85)); however, the risk became nonsignificant on adjustment for potential confounders. There was no appreciable change in hazards ratio with inclusion of variables related to access and barriers to care. Additional analyses in subgroups based on 12 different variables yielded similar negative associations. Thus, in the largest cohort of individuals with early-stage CKD to date, we could not validate an independent association of serum phosphorus with risk for death or progression to ESRD.
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Clase CM, Holden RM, Sood MM, Rigatto C, Moist LM, Thomson BKA, Mann JFE, Zimmerman DL. Should patients with advanced chronic kidney disease and atrial fibrillation receive chronic anticoagulation? Nephrol Dial Transplant 2012; 27:3719-24. [DOI: 10.1093/ndt/gfs346] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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14
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Bone-specific alkaline phosphatase concentrations are less variable than those of parathyroid hormone in stable hemodialysis patients. Kidney Int 2012; 82:100-5. [PMID: 22456600 PMCID: PMC3376309 DOI: 10.1038/ki.2012.77] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abnormalities of bone mineral metabolism and vascular calcification are prevalent in patients with kidney failure. Clinical management is based on biochemical targets, in particular parathyroid hormone (PTH) concentrations, but this has many limitations including high biological variation. A possible alternative is bone-specific alkaline phosphatase (ALP); therefore, we evaluated the biological variation of this marker in patients undergoing hemodialysis. Bone ALP was measured in non-fasting serum samples taken twice a week over a 6-week period in 22 stable hemodialysis patients and 12 healthy volunteers. The within-individual coefficients of variance were calculated and used to derive the critical difference required to be certain that an observed change was significant. The coefficient of variance for bone ALP was significantly higher in hemodialysis patients compared to healthy individuals. Seven samples were required to estimate the homeostatic set point of bone ALP, within 10%, in a hemodialysis patient. The concentration of serial bone ALP measurements would need to change by 36% between any two measurements before it can be considered a significant change. Since the biological variation of bone ALP is less than half that reported for PTH, our study provides further support for the use of bone ALP as an alternative marker of bone mineral metabolism in the setting of chronic kidney disease–mineral and bone disorder.
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15
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Weinhandl ED, Liu J, Gilbertson DT, Arneson TJ, Collins AJ. Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. J Am Soc Nephrol 2012; 23:895-904. [PMID: 22362906 DOI: 10.1681/asn.2011080761] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Frequent hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily home hemodialysis and thrice-weekly in-center hemodialysis patients between 2005 and 2008. We matched 1873 home hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the home hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, home hemodialysis associated with a 13% lower risk for all-cause mortality than in-center hemodialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78-0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78-1.09) for cardiovascular disease, 1.13 (95% CI, 0.84-1.53) for infection, 0.63 (95% CI, 0.41-0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81-1.37) for other specified cause, and 0.59 (95% CI, 0.44-0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center hemodialysis, daily home hemodialysis associates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.
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Affiliation(s)
- Eric D Weinhandl
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, MN 55404, USA.
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Atkinson MA, Lestz RM, Fivush BA, Silverstein DM. Comparative clinical outcomes between pediatric and young adult dialysis patients. Pediatr Nephrol 2011; 26:2219-26. [PMID: 21643780 DOI: 10.1007/s00467-011-1932-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 11/26/2022]
Abstract
Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initiative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18-24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0-8, 9-12, 13-17 years), and on a random sample of 5% of patients ≥ 18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01-0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04-0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002-0.09, p < 0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02-0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.
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Affiliation(s)
- Meredith A Atkinson
- Division of Pediatric Nephrology, Johns Hopkins University, 200 N. Wolfe St, Baltimore, MD 21287, USA.
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Jean G. Comment je traite les troubles phosphocalciques en cas d’insuffisance rénale chronique. Presse Med 2011; 40:1043-52. [DOI: 10.1016/j.lpm.2011.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 04/25/2011] [Indexed: 10/17/2022] Open
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18
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Chiu YW, Mehrotra R. Can we reduce the cardiovascular risk in peritoneal dialysis patients? Indian J Nephrol 2011; 20:59-67. [PMID: 20835317 PMCID: PMC2931134 DOI: 10.4103/0971-4065.65296] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Patients with end-stage renal disease (ESRD), including those treated with peritoneal dialysis (PD), have a high risk for death, particularly from cardiovascular (CV) causes. Traditional risk factors for CV disease – like hypertension, diabetes, and dyslipidemia - are highly prevalent, often severe, and more difficult to treat in dialysis patients. Development of strategies for CV risk reduction in dialysis patients is complicated by epidemiologic studies that demonstrate paradoxical associations of some of the traditional risk factors with mortality. The difficulty is enhanced by either a paucity or negative findings of studies that have tested risk modification by targeting traditional CV risk factors. It is also clear that neither the prevalence nor the severity of traditional risk factors explains the substantial increase in risk for death associated with ESRD; this has led to identification of several nontraditional risk factors. Among these, systemic inflammation, disordered mineral metabolism, and long-term CV risk from infectious complications appear the most promising. However, the evidence in favor of the importance of these risk factors is largely limited to observational studies. In this review, we present a critical analysis of the literature to assist the clinician to reduce the CV risk of ESRD patients treated with PD.
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Affiliation(s)
- Y W Chiu
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, U.S.A
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Affiliation(s)
- Sirin Jiwakanon
- Los Angeles Biomedical Research Institute, Torrance, California 90509, USA
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20
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Zhu B, Bailey SR, Mauli Agrawal C. Engineering calcium deposits on polycaprolactone scaffolds for intravascular applications using primary human osteoblasts. J Tissue Eng Regen Med 2010; 5:324-36. [DOI: 10.1002/term.327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 04/27/2010] [Indexed: 11/08/2022]
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Kalantar-Zadeh K, Shah A, Duong U, Hechter RC, Dukkipati R, Kovesdy CP. Kidney bone disease and mortality in CKD: revisiting the role of vitamin D, calcimimetics, alkaline phosphatase, and minerals. KIDNEY INTERNATIONAL. SUPPLEMENT 2010; 78:S10-21. [PMID: 20671739 PMCID: PMC5494176 DOI: 10.1038/ki.2010.189] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent evidence suggests that the traditional syndromes known as renal osteodystrophy, secondary hyperparathyroidism, and vitamin D deficiency are related to mortality in persons with moderate to advanced chronic kidney disease (CKD). The so-called 'kidney bone disease', also known as 'mineral and bone disorders', is defined to include bone disorders, mineral disarrays, and vascular calcification. We have identified 14 common and clinically relevant conditions of contemporary nature that are related to the kidney bone disease, including calcitriol (active vitamin D) deficiency, 25(OH)-vitamin D deficiency, biochemical hyperparathyroidism, relatively low parathyroid hormone (PTH) level, increased serum alkaline phosphatase (hyperphosphatasemia), elevated fibroblast growth factor (FGF)-23, high turnover bone disease, adynamic bone disease, uremic osteoporosis, vascular calcification, hyper- and hypophosphatemia, and hyper- and hypocalcemia. We present a critical review of these 14 conditions with emphasis on patient survival and other pertinent clinical outcomes. We also review unresolved controversies surrounding the management of these conditions by administration of nutritional vitamin D (ergocalciferol and cholecalciferol), vitamin D receptor activators (calcitriol, alphacalcidiol, doxercalciferol), D-mimetics (paricalcitol, maxacalcitol), calcimimetics (cinacalcet), recombinant PTH (teriparatide), and receptor activator of nuclear factor-kappaB ligand modulators (denosumab); compare mortality predictability of PTH and alkaline phosphatase; and examine potential risks of bone disorders and mineral disarrays in CKD patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90509-2910, USA.
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Winnie Chan WL, Rounsley K, Chapman E, Collings K, Dale C, De Waal S, Patel V, Tanner J, Turner E, Moore J, Borrows R. Lanthanum Carbonate Is an Effective Hypophosphatemic Agent for Hemodialysis Patients Intolerant of Other Phosphate Binders. J Ren Nutr 2010; 20:270-7. [DOI: 10.1053/j.jrn.2009.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Indexed: 11/11/2022] Open
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23
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Chiu YW, Adler SG, Budoff MJ, Takasu J, Ashai J, Mehrotra R. Coronary artery calcification and mortality in diabetic patients with proteinuria. Kidney Int 2010; 77:1107-14. [DOI: 10.1038/ki.2010.70] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Gardham C, Stevens PE, Delaney MP, LeRoux M, Coleman A, Lamb EJ. Variability of parathyroid hormone and other markers of bone mineral metabolism in patients receiving hemodialysis. Clin J Am Soc Nephrol 2010; 5:1261-7. [PMID: 20498246 DOI: 10.2215/cjn.09471209] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Clinical management of mineral bone disorder in patients with kidney failure is guided by biochemical targets, in particular parathyroid hormone (PTH) concentration. The biologic variation of PTH and other bone mineral markers was measured in hemodialysis patients to better define their role in management. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Intact PTH, biointact (whole-molecule) PTH, calcium, albumin-adjusted calcium, phosphate, and alkaline phosphatase (ALP) were measured in nonfasting samples obtained twice a week (both short-dialysis interval) over a 6-week period in 22 stable hemodialysis patients. Concurrently, samples were obtained from 12 healthy volunteers. Intraindividual coefficients of variance (CVI) were calculated and used to derive the reference change value (RCV) required to be 95% certain that a change has occurred. RESULTS CVI of all markers was significantly (P<0.05) greater in patients than in healthy volunteers. For phosphate, ALP, and PTH this implies that an increased number of samples is required to estimate an individual's homeostatic set point. CVI of intact PTH was 25.6% in hemodialysis patients and 19.2% in healthy volunteers. A greater RCV should be used for patients (72%) compared with healthy volunteers (54%). Ideally 26 specimens should be measured to estimate a patient's intact PTH homeostatic set point (within +/-10%) with 95% probability. The CVI of biointact PTH was at least as high as that for intact PTH. CONCLUSIONS The uncertainty of PTH estimation in an individual significantly undermines its value as a tool in the management of chronic kidney disease-mineral bone disorder using current management approaches.
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Affiliation(s)
- Clare Gardham
- Department of Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, United Kingdom
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Abstract
Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD). Due to an explosion in the incidence and the prevalence of Type 2 DM, the burden of CKD is expected to increase proportionately. Both DM and CKD are associated with a high incidence of cardiovascular (CV) morbidity and mortality, and it is important to understand the unique nature of CV disease in patients with the combination of these two conditions. In this report, we review the traditional and nontraditional risk factors that underlie the high risk of CV disease in this population, with a particular focus on vascular calcification, mineral metabolism, and therapeutic paradigms for the treatment of cardiovascular disease in this unique and high-risk population.
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Affiliation(s)
- Tejas Patel
- Renal Division, Brigham and Women's Hospital, Boston, MA 002120, USA
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27
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Hosaka N, Mizobuchi M, Ogata H, Kumata C, Kondo F, Koiwa F, Kinugasa E, Akizawa T. Elastin degradation accelerates phosphate-induced mineralization of vascular smooth muscle cells. Calcif Tissue Int 2009; 85:523-9. [PMID: 19806384 DOI: 10.1007/s00223-009-9297-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 09/08/2009] [Indexed: 01/12/2023]
Abstract
Medial layer vascular calcification is common in patients with end-stage kidney disease. Inorganic phosphate has been shown to accelerate the transformation of vascular smooth muscle cells (VSMCs) into osteoblast-like cells, which is thought to be a major process of medial layer calcification. Although elastin degradation is associated with medial layer calcification, the linkage between elastin degradation and the transformation of VSMCs remains to be clarified. We investigated the involvement of elastin degradation in the transformation of VSMCs. Rat VSMCs were isolated and cultured with a normal- (NP, 1.0 mM) or high- (HP, 2.5 mM) phosphate medium. An elastin-derived peptide, alpha-elastin (500 microg/ml), was also added to the normal- (NP + E) or high- (HP + E) phosphate medium. After a culture period of 2 weeks, von Kossa staining revealed mineralization in the HP group, which was accelerated by alpha-elastin, whereas alpha-elastin did not affect the mineralization at a normal phosphate concentration. The gene expression of osteoblastic differentiation factors, i.e., Runx2 or osteocalcin (OC), in VSMCs was significantly increased in the HP (Runx2 P < 0.05, OC P < 0.05) and HP + E (OC P < 0.05) groups compared with the NP and NP + E groups. Both gene and protein expressions of tissue-nonspecific alkaline phosphatase (TNAP) were significantly increased in the HP group compared with the NP and NP + E groups (P < 0.01, respectively). This increment was augmented in the HP + E group (P < 0.01). These results suggest that elastin degradation would accelerate or stabilize the process of VSMC transformation, which is induced by high phosphate through the upregulation of TNAP.
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Affiliation(s)
- Nozomu Hosaka
- Division of Nephrology, Department of Internal Medicine, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, Japan
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Plaque characterization of non-culprit lesions by virtual histology intravascular ultrasound in diabetic patients: Impact of renal function. J Cardiol 2009; 54:59-65. [DOI: 10.1016/j.jjcc.2009.03.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 01/31/2009] [Accepted: 03/25/2009] [Indexed: 11/22/2022]
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Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol 2009; 4:1089-96. [PMID: 19423571 DOI: 10.2215/cjn.00290109] [Citation(s) in RCA: 407] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Dialysis patients have a high burden of co-existing diseases, poor health-related quality of life (HR-QOL), and are prescribed many medications. There are no data on daily pill burden and its relationship to HR-QOL and adherence to therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Two hundred and thirty-three prevalent, chronic dialysis patients from three units in different geographic areas in the United States underwent a single, cross-sectional assessment of total daily pill burden and that from phosphate binders. HR-QOL, adherence to phosphate binders, and serum phosphorus levels were the three main outcome measures studied. RESULTS The median daily pill burden was 19; in one-quarter of subjects, it exceeded 25 pills/d. Higher pill burden was independently associated with lower physical component summary scale scores on HR-QOL on both univariate and multivariate analyses. Phosphate binders accounted for about one-half of the daily pill burden; 62% of the participants were nonadherent. There was a modest relationship between pill burden from phosphate binders and adherence and serum phosphorus levels; these associations persisted on multivariate analyses. There was no relationship between adherence and serum phosphorus levels. CONCLUSIONS The daily pill burden in dialysis patients is one of the highest reported to date in any chronic disease state. Higher pill burden is associated with lower HR-QOL. There are many reasons for uncontrolled serum phosphorus levels; increasing the number of prescribed pills does not seem to improve control and may come at the cost of poorer HR-QOL.
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Affiliation(s)
- Yi-Wen Chiu
- Los Angeles Biomedical Research Institute, Torrance, California, USA
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30
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Lee CT, Tsai YC, Ng HY, Su Y, Lee WC, Lee LC, Chiou TTY, Liao SC, Hsu KT. Association Between C-Reactive Protein and Biomarkers of Bone and Mineral Metabolism in Chronic Hemodialysis Patients: A Cross-Sectional Study. J Ren Nutr 2009; 19:220-7. [DOI: 10.1053/j.jrn.2008.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Indexed: 11/11/2022] Open
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WANG NINGNING, YANG JUNWEI, YU XIANGBAO, HU JIANMING, XING CHANGYING, JU XIAOBING, SHEN XIA, QIAN JUN, ZHAO XIUFEN, WANG XIAOYUN. Radial artery calcification in end-stage renal disease patients is associated with deposition of osteopontin and diminished expression of α-smooth muscle actin. Nephrology (Carlton) 2008; 13:367-75. [DOI: 10.1111/j.1440-1797.2008.00941.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mehrotra R, Martin KJ, Fishbane S, Sprague SM, Zeig S, Anger M. Higher strength lanthanum carbonate provides serum phosphorus control with a low tablet burden and is preferred by patients and physicians: a multicenter study. Clin J Am Soc Nephrol 2008; 3:1437-45. [PMID: 18579668 DOI: 10.2215/cjn.04741107] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Management of hyperphosphatemia, a predictor of mortality in chronic kidney disease, is challenging. Nonadherence to dietary phosphate binders, in part, contributes to uncontrolled serum phosphorus levels. This phase IIIb trial assessed the efficacy of increased dosages (3000 to 4500 mg/d) of reformulated lanthanum carbonate (500-, 750-, and 1000-mg tablets) in nonresponders to dosages of up to 3000 mg/d. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This 8-wk study with a 4-mo open-label extension enrolled 513 patients who were undergoing maintenance hemodialysis. Patients who achieved serum phosphorus control at week 4 with <or=3000 mg/d lanthanum carbonate entered cohort A; nonresponders were randomly assigned to receive 3000, 3750, or 4500 mg/d (cohort B). The primary outcome measure was the control rate for predialysis serum phosphorus levels at the end of week 8, among patients in cohort B. RESULTS At the end of week 4, 54% of patients achieved serum phosphorus control at dosages <or=3000 mg/d administered as one tablet per meal. Among patients who entered cohort B, control rates of 25, 38, and 32% for patients who were randomly assigned to 3000, 3750, or 4500 mg/d lanthanum carbonate, respectively, were achieved, with no increase in adverse events. Patients and physicians reported significantly higher levels of satisfaction with reformulated lanthanum carbonate compared with previous phosphate binders, partly because of reduced tablet burden with higher dosage strengths. Physicians and patients also expressed a preference for lanthanum carbonate over previous medication. CONCLUSIONS Reformulated lanthanum carbonate is an effective phosphate binder that may reduce daily tablet burden.
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Affiliation(s)
- Rajnish Mehrotra
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90502, USA.
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Furukawa KI. Pharmacological aspect of ectopic ossification in spinal ligament tissues. Pharmacol Ther 2008; 118:352-8. [DOI: 10.1016/j.pharmthera.2008.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Accepted: 03/17/2008] [Indexed: 01/07/2023]
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Brancaccio D, Bommer J, Coyne D. Vitamin D receptor activator selectivity in the treatment of secondary hyperparathyroidism: understanding the differences among therapies. Drugs 2008; 67:1981-98. [PMID: 17883283 DOI: 10.2165/00003495-200767140-00002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Secondary hyperparathyroidism (SHPT) is a common and serious consequence of chronic kidney disease (CKD). SHPT is a complex condition characterised by a decline in 1,25-dihydroxyvitamin D and consequent vitamin D receptor (VDR) activation, abnormalities in serum calcium and phosphorus levels, parathyroid gland hyperplasia, elevated parathyroid hormone (PTH) secretion, and systemic mineral and bone abnormalities. There are three classes of drugs used for treatment of SHPT: (i) nonselective VDR activators or agonists (VDRAs); (ii) selective VDRAs; and (iii) calcimimetics. The VDRAs act on the VDR, whereas the calcimimetics act on the calcium-sensing receptor. Calcimimetics are commonly used in conjunction with VDRA therapy. By virtue of the differences in their chemical structure, the nonselective and selective VDRAs differ in their effects on gene expression, and ultimately parathyroid gland, bone and intestine function. Medications in all three classes are effective in suppression of PTH; however, clinical studies show that calcimimetics are associated with an unfavourable tolerability profile and hypocalcaemia, whereas nonselective VDRAs, and to a lesser extent selective VDRAs, are associated with dose-limiting hypercalcaemia and hyperphosphataemia. Selective VDRAs also have minimal undesirable effects on calcium absorption in the intestine, and calcium and phosphorus mobilisation in the bone compared with nonselective VDRAs. Calcium load in patients with CKD can lead to vascular calcification, accelerated progression of cardiovascular disease and increased mortality. High serum phosphorus levels are also associated with adverse effects on cardiorenal function and survival. Recent evidence suggests that VDRAs are associated with a survival benefit in CKD patients, with a more favourable effect with selective VDRAs than nonselective VDRAs. Paricalcitol, a selective VDRA, is reported to exert specific effects on gene expression in various cell types that are involved in vascular calcification and the development of coronary artery disease. This article examines the molecular mechanisms that determine selectivity of VDRAs, and reviews the evidence for clinical efficacy, safety and survival associated with the three drug classes used for treatment of SHPT in CKD patients.
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Affiliation(s)
- Diego Brancaccio
- Renal Division, Ospedale San Paulo, University of Milan, Via di Rudini 8, 20142 Milan, Italy.
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Caglar K, Yilmaz MI, Saglam M, Cakir E, Acikel C, Eyileten T, Yenicesu M, Oguz Y, Vural A, Carrero JJ, Axelsson J, Lindholm B, Stenvinkel P. Short-term treatment with sevelamer increases serum fetuin-a concentration and improves endothelial dysfunction in chronic kidney disease stage 4 patients. Clin J Am Soc Nephrol 2007; 3:61-8. [PMID: 18057307 DOI: 10.2215/cjn.02810707] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Vascular calcification and endothelial dysfunction contribute to the development of cardiovascular disease in patients with chronic kidney disease (CKD). Sevelamer, a non-calcium-based phosphate binder, has been shown to attenuate cardiovascular calcification in CKD patients, although the exact mechanism has not been clarified. This study was designed to investigate the effect of short-term sevelamer treatment on both serum fetuin-A concentrations and endothelial dysfunction seen in CKD patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Fifty nondiabetic stage 4 CKD patients whose phosphate levels were > or =5.5 mg/dl were enrolled in this 8-wk randomized prospective study. Thirty-six healthy volunteers served as matched controls. Patients were treated with either sevelamer (n = 25, 12 males) or calcium acetate (n = 25, 13 males). Fetuin-A, high-sensitivity C-reactive protein, Ca x PO4 product, flow-mediated dilation (FMD), insulin, and homeostasis model assessment (HOMA) were obtained at baseline and after the treatment period. RESULTS As expected, CKD patients had significantly lower levels of fetuin-A and FMD, and significantly higher levels of intact parathyroid hormone, Ca x PO4 product, and high-sensitivity C-reactive protein than controls (P < 0.001 for all). The use of sevelamer led to a significant increase in the fetuin-A concentration with improvement in FMD, whereas no significant difference was observed in the calcium acetate group. In a multiple regression analysis, FMD levels were independently related to fetuin-A both before (beta = 0.63, P < 0.001) and after (beta = 0.38, P = 0.004) treatment. CONCLUSIONS This small, randomized, prospective study shows that short-term sevelamer treatment significantly increases fetuin-A levels and improves FMD in nondiabetic stage 4 CKD patients.
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Affiliation(s)
- Kayser Caglar
- Department of Nephrology, Gülhane School of Medicine, Etlik-Ankara, Turkey
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Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Battleground: Chronic Kidney Disorders Mineral and Bone Disease—Calcium Obsession, Vitamin D, and Binder Confusion. Clin J Am Soc Nephrol 2007; 3:168-73. [DOI: 10.2215/cjn.03850907] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mehrotra R. Emerging role for fetuin-A as contributor to morbidity and mortality in chronic kidney disease. Kidney Int 2007; 72:137-40. [PMID: 17625580 DOI: 10.1038/sj.ki.5002355] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Vascular calcification (VC) is an important reason for the high burden of vascular disease among chronic dialysis patients. Chronic kidney disease (CKD) is associated with increased promoters and decreased inhibitors of VC. The circulating levels of fetuin-A, a well-described inhibitor of calcification, regulate the cell-dependent process of osteogenesis. It is not surprising that the low circulating fetuin-A levels are associated with a greater prevalence and/or severity of VC and increased risk for all-cause and cardiovascular mortality. However, high circulating fetuin-A levels appear to induce insulin resistance and, in non-dialyzed subjects with diabetic nephropathy, are directly related to VC burden. These findings underscore the need to further clarify the multiple, systemic effects of fetuin-A and its role in health and various stages of CKD.
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Affiliation(s)
- R Mehrotra
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California 90502, USA.
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Covic A, Gusbeth-Tatomir P, Goldsmith DJA. VASCULAR CALCIFICATION IN PATIENTS WITH KIDNEY DISEASE: Vascular Calcification-A New Window on the Cardiovascular System: Role of Agents Used to Manipulate Skeletal Integrity. Semin Dial 2007; 20:158-69. [PMID: 17374091 DOI: 10.1111/j.1525-139x.2007.00265.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Adrian Covic
- Nephrology Clinic, "Dr. C. I. Parhon" University Hospital, Iasi, Romania.
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